The topic in this booklet focuses on the aftereffects of
interpersonal trauma. There is considerable evidence that survivors of interpersonal
trauma experience a variety of effects from their experiences with interpersonal trauma.
Some of these effects are characterized by feelings of isolation and alienation, feelings
of stigmatization and being different from others, fear of intimacy and avoidance of
relationships, and an inability to trust others. These result not only in problems in
general social relationships, but also in relationships with men, women, and parents.
Problems with partners in a close relationship may also arise, with a high incidence of
revictimization. In addition, there is some evidence that survivors experience problems in
their own parenting skills and their relationship with their children.

Who are the Survivors?

Interpersonal trauma and abuse takes place everyday. The victims of abuse are of all ages,
races, and socioeconomic strata. However, this section will focus more upon a more
specific type of interpersonal abuse; childhood maltreatment. In general, the child
victims of abuse and neglect are relatively young (average age is 7.4 years). Neglect is
most often reported when children are quite young (infancy and toddlerhood), with
incidence declining with age. In contrast, reports of sexual and emotional maltreatment
occur most frequently among older, school-aged children and adolescents. Physical abuse
affects a sizable portion of all age groups. The highest rate of physical injury, however,
is found among the older children (12-17 years of age). Although this latter finding seems
surprising in light of the public image of this problem centering on small children, it
corresponds with increasing parent-child conflict that occurs during adolescent
development.

With the exception of sexual abuse (where females comprise 85% of the victims), boys and
girls are reported at approximately the same rate for physical abuse and neglect. Race of
the victim seems to be representative of the population at large.

Long-Term Aftereffects of Interpersonal
Abuse:

Behaviors and Relationship Response

While no single pattern of distress can be said to exist among all adult survivors of
interpersonal trauma, a number of patterns of behaviors appear to be prominent among adult
survivors. Taken together, the studies of interpersonal abuse in the literature provide
strong support for the behavioral and psychological toxicity of interpersonal abuse. It
appears, in this regard, that interpersonal trauma can have relatively direct and
sustained impacts on psychological functioning as well as motivating behaviors that, while
immediately adaptive, often have longer-term self-injurious consequences (for instance,
substance abuse, eating disorders, self-mutilation).

Intimacy Disturbance

Research and clinical observation suggest that interpersonal abuse is associated
with long-term alterations in social functioning. Adult survivors of interpersonal trauma
report poor social adjustment, feelings of isolation, fear and distrust of others, and
difficulty in forming and sustaining intimate relationships. Experiencing repeated
uncontrollable life events decreases an individuals ability to perceive future
relationships as supportive or helpful and may, therefore, lead to greater difficulty in
establishing trust in others.

Adult survivors oftentimes see themselves as unworthy of relationships with people they
consider good or healthy. It is believed that survivors oftentimes may attempt to gain
mastery over their abuse experience by re-creating it in the form of involvement with
abusive others.

Sexual intimacy is often reported as a problematic area for survivors of interpersonal
abuse. Such problems may present themselves as sexual dysfunction related to fears of
vulnerability and revictimization, a general distrust of sex partners and men or women in
general, a tendency to be dependent on or over-idealize those with whom they form close
relationships, and a history of multiple, superficial, or brief sexual relationships that
quickly end as intimacy develops.

Perhaps one of the most disruptive and painful aspects of childhood interpersonal abuse is
its impact on the survivors ability to trust. Requiring as it does a suspension of
defensive activities and an assumption of safety at the hands of another, trust is
especially difficult for survivors who were maltreated as children.

The untreated
survivors expectation of continued victimization, difficulties with trust,
adversarial perspective, and tendency to overreact to perceived rejection or
devaluation may lead to considerable isolation from and rejection by others.

Revictimization

When survivors do form close or long-term stable relationships, they may compulsively
attach themselves to partners who frequently resemble the abuser. One possible explanation
may be that the survivor has not learned the necessary skills either to protect
himself/herself adequately, or to assert himself/herself in a relationship. The
survivors expectation of what constitutes a good relationship, and the
survivors rights within that, may have become distorted. Another explanation for
revictimization may be that trauma can be repeated on behavioral, emotional, and
physiological levels. The confusion of pain and love may cause individuals to develop
strong ties with people who are physically, emotionally, or sexually threatening to them.
In the presence of overt threat, the survivor may experience a return of the earlier
interpersonal trauma and thus return to primitive and archaic behavior patterns.

Use of Psychoactive Substances

Studies indicate that substance abuse is often inextricably associated with
chronic experiences of interpersonal abuse, trauma, maltreatment, and pain, and that such
substances are often used for temporary relief of--and survival despite--post-abuse
trauma. Often even more powerful than dissociative states, alcohol and psychoactive drugs
are immediate painkillers for many individuals who suffer anxiety, depression,
or upsetting memories.

The
acute effects of alcohol and drugs are manifold:

temporary elimination of
emotional turmoil and pain

inducement of some level of
euphoria or well-being

interference with memory of
painful events

provision of an opportunity to
express otherwise inhibited painful feelings

an opportunity for the user to
develop a minimally demanding peer group

Tension Reducing Behaviors

Over time, the survivor learns to deal with acute or impending abuse-related distress by
quickly resorting to distracting, calming, or anesthetizing behaviors. Indiscriminate and
frequent sexual activity, substance abuse, bingeing or chronic overeating, spending
sprees, risk-taking activities, and self-mutilation are common behaviors that survivors
find themselves involved with. In the face of extreme abuse-related distress, often
restimulated by revictimization and/or perceived abandonment or rejection, the survivor
may engage in any number of external activities that anesthetize, soothe, interrupt, or
forestall painful emotional states.

Compulsive Sexual Behavior

Also found among some abuse survivors are periods of frequent, short-term sexual
behaviors, most typically with a number of different sexual partners. The choice of
multiple sexual partners by some survivors appears to represent powerful needs for
closeness and intimacy, as a result of deprivation in these areas in the past, and yet,
fearfulness regarding the vulnerability inherent in sustained intimacy. As well,
compulsive sexual behavior can be utilized to temporarily soothe, mask, or dispel chronic
abuse-related dysphoria. Many abuse survivors report involvement in one-night
stands or repetitive masturbation during times of depression, loneliness, or
perceived abandonment or rejection by others, or during periods of uncontrollable
rumination and recall of abuse-related painful events. These behaviors may be viewed as
consciously or unconsciously chosen coping mechanisms invoked to modulate painful internal
experiences rather than inappropriate behavior.

Long-Term Aftereffects of Interpersonal
Abuse:

Psychological Responses

Significant psychological distress may be a long-term aftereffect of interpersonal
abuse. Interpersonal abuse can be so potentially hurtful during childhood since the abuse
is taking place at the most critical developmental times for the child. It is during
childhood when assumptions about self, others, and the world are being formed; when their
relations to their own internal states are being established; and when coping and
affiliate skills are first acquired.

Posttraumatic Effects

Especially prominent for interpersonal abuse survivors are post-traumatic stress
disorder-related intrusive symptoms. The most disturbing of these, by virtue of their
uncontrollability and perceived bizarreness, are flashbacks. These sudden, intrusive
sensory memories often include visual images of the abusers face or aspects of the
actual interpersonal assault taking place, hearing the perpetrators voice, choking
sensations related to forced oral intercourse, smelling the perpetrators
alcohol-laden breath, and feeling hands grabbing ones legs, thighs, or genitals.

The post-traumatic symptoms of abuse survivors appear to involve more autonomic arousal
(e.g., tension, jumpiness, flinching), avoidance of abuse-related thoughts or
stimuli, violent nightmares, and intrusive thoughts of being violent or of suddenly being
injured than do those produced by interpersonal abuse alone.

Cognitive Distortions

Psychologists generally agree that people make significant assumptions about themselves,
others, the environment, and the future based upon childhood learning. Because the
experiences of former child interpersonal abuse survivors are by definition usually
negative, these assumptions and self-perceptions are often distorted. As an example,
survivors may overestimate the amount of danger or adversity in the world, and
underestimate their own self-efficacy and self-worth.

It is believed that abuse-related negative cognitions probably arise from two sources:
psychological reactions to abuse-specific events, and the survivors attempt to make
sense of the abuse.

Abuse-Specific Responses

Perceptions of helplessness and chronic danger are thought to result from the fact that
the abuse occurred when the victim was more often than not a child, and thus physically
and psychologically unable to resist or defend against the abuser. Because such
experiences were often chronic and ongoing, feelings of hopelessness regarding the future
were also likely. Similarly, the child may have made assumptions about his or her inherent
badness, based on misinterpretation of maltreatment as, in fact, punishment for unknown
transgressions.

A common impact of interpersonal victimization is hypervigilance to danger--not only for
potential physical injury, but also for psychological trauma such as betrayal,
abandonment, or injustice. This expectation of injury may lead to hyperactivity in the
presence of real, potential, or imagined threats. Not only do survivors identify potential
abandonment in the everyday actions of significant others, they tend to respond to such
perceptions with greater emotional or behavioral intensity than others might deem
appropriate.

Finally, negative self-evaluation may arise from the survivors attempt to make sense
of his/her abuse. This process can lead to self-deprecating conclusions, including that
one deserved the abuse and is inherently bad. Such cognitive reactions to child abuse and
the resultant attempts to draw logical conclusions from it appear to produce what
initially seems illogical: passivity, self-blame, and low self-esteem as a result of being
unfairly treated by another. The extent of self-hatred that these dynamics can engender is
often startling, as is its endurance during treatment. This dynamic is sustained seemingly
by the self-perpetuating belief that I was (and continue to be ) hurt because of my
badness, and evidence of my badness is that I have been (continue to be) hurt.

Altered Emotionality

Depression. Study after study indicates that depression is the symptom most commonly
reported among adult survivors of interpersonal abuse. Clinical experience suggests that
adults with histories of interpersonal abuse are more prone to major depressive episodes
as well as dysthymia, which is a milder form of depression characterized by chronic
sadness and unhappiness, low self-esteem, self-blame, and perceived helplessness.

Anxiety. Because interpersonal abuse is, by its nature, threatening and disruptive, it
should not be surprising that survivors of such maltreatment are prone to feelings of
fearfulness or anxiety, even well after abuse has transpired. Clinical experience suggests
that adults with histories of interpersonal abuse frequently present with cognitive,
classically conditioned, and somatic components of anxiety. Abuse-related anxiety
typically involves 1) hypervigilance to danger in the environment, whether objectively
warranted or not; 2) preoccupation with control, with the belief that even a slight loss
of self-determination or self-protection could lead to danger or catastrophe; and 3)
misinterpretation of objectively neutral or positive interpersonal stimuli as evidence of
threat or danger.

Dissociation. Dissociation can be thought of as a defensive
disruption in the normally occurring connections among feelings, thoughts, behavior, and
memories, consciously or unconsciously invoked in order to reduce psychological distress.
It can be hypothesized that dissociation is a very functional dynamic for the survivor.
This dynamic can help the survivor escape from the constraints of reality. Dissociation
can provide a means of containing traumatic memories and emotions outside of normal
conscious awareness, and is a means by which the survivor can create an alteration or
detachment of sense of self in order that trauma happens to someone else or a
depersonalized self. Finally, dissociation can provide an analgesia or means of reducing
the emotional pain.

There are three common types of dissociation that take place which relate specifically to
alterations in thoughts, feelings, or awareness. They are disengagement,
detachment/numbing, and observation. Disengagement involves a cognitive separation of the
individual from his or her environment at times of stress or trauma. Detachment refers to
the instances when an individual copes with the intensity of negative feelings associated
with certain thoughts, memories, or ongoing events, by emotionally shutting down. This
allows an individual to engage in necessary activities without being distracted or
immobilized by psychological pain. Finally, observation occurs when individuals experience
themselves as watching (as opposed to participating in) events in which they are directly
involved.

Philosophy of Treatment

The most important truism of interpersonal trauma recovery is that the individuals who
were abused are survivors. These individuals have persevered despite often extreme
interpersonal trauma and later abuse-related difficulties. The most important underlying
premise of abuse-focused treatment is the individual I work with is not mentally ill or
suffering from a defect, but rather is an individual whose life has been shaped in part,
by ongoing adaptation to a toxic environment. Thus, my goal of therapy is less the
survivors recovery than his or her continued growth and development. In this
respect, it is critical that therapy be a process that utilizes the strengths and already
existing skills of the client to move beyond his/her current level of adaptive
functioning.

Wound Care: Awareness and Integration

Awareness and integration are the twin foci upon which treatment is predicated. Treatment
is a supportive and safe effort at facilitating an integrated awareness of the present and
the past, of previously split-off or compartmentalized internal experience. Through
dissociation, avoidance, denial, and other defensive strategies, the survivor can devote
considerable psychological resources to reduction of abuse-related pain.

My approach to treatment endorses an
entirely different set of principles. I emphasize the necessity of greater awareness of
the past and present. Among the tasks inherent in the process of reworking the abuse
period is the survivors ability to experience simultaneous contradictory feelings
(e.g., anger and love, or fear and rage) without defensively dampening one and
intensifying the other, or rapidly alternating between the two. I think it is important
that the survivor develop the capacity to experience painful events directly without
reflexive defensive operations such as dissociation or denial. The end result of this
psychological healing is the survivor will experience greater psychological functioning in
the here-and-now where problem solving and adjustment are usually preferable
to defensive avoidance.

Goals of Treatment

My goals in working with any client are 1) the client
experience relief from his/her symptoms, 2) the client experience resolution of any
intrusive traumatic memories that he/she may be experiencing, 3) the client acquire a
hopeful and nonsymptomatic orientation toward the future. These end results are the
outcome of a therapeutic process that strongly emphasizes an active utilization of the
clients present life resources and images of future goals and possibilities. Such a
process is predicated upon the assumption that any construction of a solution is a joint
process between client and therapist, with the therapist taking responsibility for
empowering the client to create and experience his/her own uniquely meaningful and
effective therapeutic changes.

Resolving Interpersonal Trauma

The resolution of interpersonal abuse and trauma is a very complex, yet very achievable
process. When working with survivors of interpersonal trauma, I think of resolution in the
following way:

1)
Providing stabilization and relief for the client from symptoms stemming from or related
to the interpersonal trauma.

2)
Altering feelings associated with memories of trauma, so that the memories and/or
flashbacks are no longer intrusive or painfully prevalent in the clients daily life.

3)
Developing a positive, practical, and healthy future orientation that results in
nonsymptomatic patterns and, more importantly, in the client living what he/she would
consider a satisfying life.

Conclusion

In general, the process of resolution therapy for interpersonal abuse and trauma is of a
long-term, rather than a short-term nature. Long-term treatment is seen as needed because
of the generally pervasive effects of the abuse, the compounding of effects over time, and
the complexities of post-traumatic responses. Because of the intensity of emotions
inherent in trauma, uncovering must proceed at a pace that is tolerable to the survivor.
The unique characteristics and dynamics of interpersonal trauma demand a unique treatment
approach which must be individualized to the survivor. This involves not only the use of a
broad range of techniques but also a multimodal and integrated treatment approach.
Whichever techniques or modalities are employed, they must reflect a comprehensive
approach which encompass the emotional, cognitive, and behavioral components inherent in
the difficulties experienced by individual survivors. Each of these components represents
aspects of the traumagenic impact of interpersonal trauma and contribute in varying
degrees to the long-term psychological and behavioral effects of the trauma. The healing
process for adult survivors is complete when the survivor no longer feels contaminated by
the survivors thoughts and behavior patterns. Instead of the abuse exerting control
over the survivors life in eliciting unconscious, maladaptive archaic behavior
patterns, the survivor is able to take control of his/her life and make his/her
feelings and thoughts conscious, enabling the survivor to make choices rather than being
internally driven or directed. The survivor has learned to trust himself/herself and
his/her perceptions and not be fearful of taking risks in expressing and exploring his/her
new self. The survivor will be able to embrace life by reclaiming their personhood, their
sexuality, and the unpolluted self which has been in hiding since commencement of the
interpersonal trauma.

What Can Family Members of Survivors Do?

Beverly
Engel, in her book, Partners in Recovery, lists the following things for
loved ones of survivors to do.